Human Rights Joint Risk Assessment and Management Plan

Title of guidance:

Human Rights Joint Risk Assessment and Management Plan (HR-JRAMP) - A Human Rights Based Approach

Author: Dr Beth Greenhill et al, Mersey Care NHS Trust in association with BIHR

HR-JRAMP
Year published: 2011
Length: 55 pages (without appendices and references)
Format: PDF (3.7Mb)
Other formats: No other formats indicated
Producer/ Publisher: Mersey Care NHS Trust
Type of organisation: Public authority

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Categories:

Health | In-house service guidance | Human Rights Act | European Convention on Human Rights | GB wide| Case studies

Audience: Service management | Front-line service personnel | Policy managers and directors

Topics: Human rights | equality | assessing risk | proportionality | balancing competing rights | autonomy | safeguarding | best interests

Abstract

This document provides a human rights-based framework for use by social workers and clinicians to assess and manage risks associated with adults with a learning disability who present a likely and serious risk of harm to either themselves or others. Its approach is to balance the human rights of service users, their carers and their communities. Produced by Mersey Care NHS Trust, this 2011 edition explains what it means to take a human rights-based approach to complex care and risk management, with a step-by-step guide to the procedure and comprehensive guidance notes. It reflects the current state of research into risk assessment and its links to current practice, as well as current legislation and policy. The manual may be copied for use within NHS organisations if suitably credited. It can be used in conjunction with other tools produced by Mersey Care for service users with learning disabilities.

Key human rights messages in this guidance

  • Human rights can be used to ensure that risk management practice is lawful, balances the interests of all those involved, and is proportionate - that is, appropriate and not excessive in the circumstances
  • Risk assessment is not something that should be 'done to' someone: the person being assessed should be as thoroughly involved in the process as possible.
  • An emphasis on proactive rather than reactive strategies is more likely to be consistent with human rights.

Full review of this guidance

Introduction

'Put simply, we feel that we can positively manage and balance risk, if we can support service users, their carers and their communities to access and balance their rights.' This is the main message from this unique tool for social workers and clinicians who wish to ensure that their risk management practice:

  • is lawful,
  • balances the interests of all those involved in a package of care, and
  • is proportionate - that is, appropriate and not excessive in the circumstances.

The Human Rights Joint Risk Assessment and Management Plan (known as HR-JRAMP) differs from other tools in that it expressly incorporates human rights values and uses them to assess and balance risk.

It is also distinctive in that it builds in space for reflection. At different points in the process, practitioners are prompted ask themselves whether they are acting according to human rights values and to check for any unwitting bias or assumptions they might have.

The document emphasises that risk assessment is not something that should be 'done to' people: the person being assessed should be as thoroughly involved in the process as possible. Mersey Care NHS Trust - which produced this manual - has also produced tools to assist people with learning disabilities to assess the risks that they might pose or that other might pose to them.

Legal and policy context

The HR-JRAMP document is in line with:

  • the Department of Health's 'Valuing People Now' strategy
  • current legislation - the Mental Capacity Act 2005; Mental Health Act 2007 and Deprivation of Liberty Safeguards 2009, and
  • recent research evidence.

It reflects the fact that human rights principles are now explicit in the NHS constitution and in the approach of the Care Quality Commission.

It places great emphasis on the inclusion of service users, which is an essential part of a human rights based approach to healthcare. It will support practitioners to respond to other policies encouraging service user involvement, including the 2010 White Paper, 'Equity and Excellence: Liberating the NHS'.

Human rights values

The document embeds into the process of assessing and managing the risk the human rights values known as FREDA:

  • fairness
  • respect
  • equality
  • dignity
  • autonomy

For example:

  • ensuring autonomy requires that service users and carers are supported to judge the potential benefits as well as the potential harms of any situation.
  • to ensure equality, any risk assessment should take into account and respond to a person's age, race, religion, spirituality, culture, gender, sexual orientation, disability and communication needs.

Proportionality

At the heart of the HR-JRAMP is the principle of proportionality. This can be summarised as 'not using a sledgehammer to crack a nut'. It ensures that any restriction of a person's human rights is kept to a minimum.

When considering if a strategy is proportionate, the person assessing the risk should ask:

  • What will be left of the person's rights if the strategy is employed?
  • Is there an alternative strategy that would be less drastic?

Case example:
Calvin displayed self-injurious behaviour, including pulling his own hair out and attempting to bite his hands. These incidents occurred roughly once a week and could last for half a day. The management team at Calvin's day centre decided to introduce splints to ensure he didn't seriously hurt himself. Over a five-year period, the time Calvin spent wearing the splints increased until he spent most days in them. This risked violating his right not to be treated in an inhuman or degrading way. In particular, the amount of time Calvin spent wearing the splints was not proportionate to the self-injurious behaviour. The intervention was reviewed using a human rights based approach to see if it was proportionate to the risk. As a result, staff systematically reduced the amount of time Calvin wore the splints. The splints are now only used when his behaviour poses a significant risk to his own well-being.
Source: Human Rights Joint Risk Assessment and Management Plan, 2011, p.12.

Being proactive

The principle of proportionality means that, in risk management, an emphasis on proactive rather than reactive strategies is more likely to be consistent with human rights. Proactive strategies aim to reduce the occurrence of risk or challenging behaviours.

Case example:
Joe is a young man with autism. Joe was reported by care staff to be trying to hit and bite them, usually in the mornings. Staff were trying to manage Joe's aggression reactively by using physical intervention techniques for extended periods of time. This risked violating Joe's right not to be treated in an inhuman or degrading way. After looking at when and why incidents occurred, staff realised Joe would become aggressive when they were trying to assist him to get washed. After speaking to Joe's mum, staff realised that to wash Joe as a child, she had developed a highly structured shower routine which he was used to following every day. They proactively adopted this routine and the physical aggression they were experiencing from Joe reduced dramatically.
Source: Human Rights Joint Risk Assessment and Management Plan, 2011, p.14.

Making balanced decisions

The manual supports practitioners to take balanced decisions; for example, to balance the service user's rights against those of others, or to balance different rights for the same service user.

Case Example
Melissa is a service user with a learning disability who seriously self harms and leaves her package of care without support. When she leaves her carers, Melissa engages in unprotected sex with strangers. She has tried to take her own life on previous occasions when alone in the community. Melissa is on a section of the Mental Health Act. Staff have placed restrictors on Melissa's window to prevent her from leaving. This interferes with Melissa's right to liberty - a 'limited' right - to protect her right to life, which is an 'absolute' right that can never be interfered with. In this instance staff, are attempting to balance Melissa's right to life against her right to liberty. As Melissa is under a section of Mental Health Act her right to liberty can legally be restricted.
Source: Human Rights Joint Risk Assessment and Management Plan, 2011, p.14.

Using the HR-JRAMP

The document contains detailed guidance on the process of completing a risk assessment and constructing a risk management plan. It includes a blank recording form and explains how this should be filled in with the involvement of the person being assessed to ensure a thorough analysis of risk and a robust plan for its management.

For those wish to read further, there is a section analysing recent research on approaches to assessing and managing risk. This cites evidence that people with learning disabilities have low levels of awareness of their own human rights. It includes references to several 'easy read' human rights guides.

Date of review

March 2011

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